Source · Deaths in custody

PPO Fatal Incident Reports

6,401 incidents 5,674 published 1,165 recommendations 1,633 self-inflicted 3,373 natural causes

Deaths in custody investigated by the Prisons and Probation Ombudsman. 26% of deaths are self-inflicted. Source: PPO.

Learning & thematic publications

74 cross-establishment publications

Learning Lessons Bulletins (50), thematic reviews (2), consultation responses (11), Policy into Practice (5) and annual reports (6): the systemic patterns the Ombudsman draws from many investigations.

TitleTypeDateSource
PPO response to JSC Inquiry into Children and Young Adults in the Secure Estate  Consultation response Jun 2026 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 22: Self-inflicted deaths in reception prisons Learning Lessons Bulletin Mar 2026 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 21: Segregation Learning Lessons Bulletin Mar 2026 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 20: Epilepsy Learning Lessons Bulletin Nov 2025 PDF
Annual Report 2024 to 2025 Annual report Jul 2025 PDF
Policy into Practice: Handling of prisoners’ property Policy into Practice Mar 2025 PDF
Policy into Practice: Handling of property complaints Policy into Practice Mar 2025 PDF
Complaints Investigations Learning Lessons Bulletin Issue 11: Property complaints Learning Lessons Bulletin Mar 2025 PDF
PPO response to JSC Tackling Drugs in Prison Inquiry Consultation response Feb 2025 PDF
PPO response to JHAC Inquiry into Prison Culture Consultation response Feb 2025 PDF
PPO response to JSC inquiry into Rehabilitation and Resettlement Consultation response Feb 2025 PDF
Policy into Practice: Emergency Response Policy into Practice Jan 2025 PDF
PPO response to the Independent Sentencing Review 2024/25 call for evidence Consultation response Jan 2025 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 19: Post-release death investigations 2 Learning Lessons Bulletin Jul 2024 PDF
Annual report 2022-23 Annual report Jul 2024 PDF
Annual Report 2023-24 Annual report Jul 2024 PDF
Policy into practice: Use of force Policy into Practice Feb 2024 PDF
PPO response to the inquiry into prison population and capacity Consultation response Nov 2023 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 18: Self-inflicted deaths of IPP prisoners Learning Lessons Bulletin Sep 2023 PDF
Investigating deaths after release from prison – a pilot evaluation Learning Lessons Bulletin Jan 2023 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 17: Post-release death investigations Learning Lessons Bulletin Jan 2023 PDF
PPO response to the inquiry into the Prison Operational Workforce Consultation response Jan 2023 PDF
Annual Report 2021-22 Annual report Oct 2022 PDF
Policy into Practice: Use of restraints on escort Policy into Practice Sep 2022 PDF
PPO Response to the Inquiry into IPP sentences Consultation response Jan 2022 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 16: Second wave COVID-19 related deaths Learning Lessons Bulletin Dec 2021 PDF
Annual Report 2020-21 Annual report Sep 2021 PDF
PPO responses to the Inquiry into Women in Prison Consultation response Aug 2021 PDF
Fatal Incident Investigations Learning Lessons Bulletin Issue 15: COVID-19 PPO fatal incident investigations Learning Lessons Bulletin Feb 2021 PDF
Complaints Investigations Learning Lessons Bulletin Issue 10: COVID-19 PPO Complaints Learning Lessons Bulletin Dec 2020 PDF

Incidents

6,401 records
Name Establishment Cause Status Date of death Recs
Individual at Morton Hall IRC IRC Morton Hall IRC Other Published 3 Oct 2017
Individual at Dartmoor HMP Dartmoor Natural Published 3 Oct 2017
Individual at Woodhill HMP Woodhill Natural Published 2 Oct 2017
Individual at Elmley HMP Elmley Other Published 2 Oct 2017
Individual at Isle of Wight HMP Isle of Wight Natural Published 29 Sep 2017
Individual at Stafford HMP Stafford Natural Published 28 Sep 2017
Individual at High Down HMP High Down Natural Published 28 Sep 2017
Individual at Holme House HMP Holme House Natural Published 28 Sep 2017
Individual at Nottingham HMP Nottingham Other Published 27 Sep 2017
Individual at Humber HMP Humber Natural Published 27 Sep 2017
Individual at Stafford HMP Stafford Natural Published 25 Sep 2017
Individual at Lincoln HMP Lincoln Homicide Published 25 Sep 2017
Individual at Featherstone HMP Featherstone Other Published 23 Sep 2017
Individual at Northumberland HMP Northumberland Natural Published 21 Sep 2017
Huang, Xi-Biao IRC Dungavel Natural Published 19 Sep 2017
Individual at Winchester HMP Winchester Self-inflicted Published 18 Sep 2017
Individual at Liverpool HMP Liverpool Self-inflicted Published 17 Sep 2017
Individual at Nottingham HMP Nottingham Self-inflicted Published 17 Sep 2017
Individual at Nottingham HMP Nottingham Self-inflicted Published 13 Sep 2017
Individual at Oakwood HMP Oakwood Natural Published 12 Sep 2017
Individual at Harmondsworth IRC Harmondsworth Self-inflicted Published 7 Sep 2017
Individual at Peterborough HMP Peterborough Natural Published 6 Sep 2017
Individual at Bure HMP Bure Natural Published 5 Sep 2017
Individual at Bedford HMP Bedford Self-inflicted Published 2 Sep 2017
Individual at Featherstone HMP Featherstone Natural Published 31 Aug 2017
Individual at Whatton HMP Whatton Natural Published 30 Aug 2017
Individual at Whatton HMP Whatton Natural Published 29 Aug 2017
Individual at Hindley HMP Hindley Natural Published 28 Aug 2017
Individual at Stoke Heath HMP Stoke Heath Natural Published 25 Aug 2017
Individual at Thameside HMP Thameside Other Published 23 Aug 2017
Individual at Elizabeth Fry Elizabeth Fry Other Published 23 Aug 2017
James Thomas HMP Risley Other Published 20 Aug 2017 2
Individual at Isle of Wight HMP Isle of Wight Self-inflicted Published 19 Aug 2017
Individual at Oakwood HMP Oakwood Natural Published 19 Aug 2017
Individual at Featherstone HMP Featherstone Natural Published 17 Aug 2017
Individual at Northumberland HMP Northumberland Natural Published 17 Aug 2017
Individual at Usk and Prescoed HMP Usk and Prescoed Natural Published 17 Aug 2017
Individual at Dartmoor HMP Dartmoor Natural Published 16 Aug 2017
Individual at Norwich HMP Norwich Natural Published 15 Aug 2017
Individual at Durham HMP Durham Self-inflicted Published 14 Aug 2017
Individual at Buckley Hall HMP Buckley Hall Self-inflicted Published 14 Aug 2017
Individual at Norwich HMP Norwich Natural Published 13 Aug 2017
Individual at Birmingham HMP Birmingham Natural Published 12 Aug 2017
Individual at Birmingham HMP Birmingham Natural Published 12 Aug 2017
Individual at Holme House HMP Holme House Self-inflicted Published 12 Aug 2017
Individual at Bure HMP Bure Natural Published 10 Aug 2017
Individual at Stoke Heath HMP Stoke Heath Natural Published 10 Aug 2017
Individual at Highpoint HMP Highpoint Natural Published 9 Aug 2017
Individual at Littlehey HMP Littlehey Natural Published 9 Aug 2017
Individual at Usk and Prescoed HMP Usk and Prescoed Homicide Published 8 Aug 2017